HEADACHE/ HEAD PAINBrittny Alexander

Duvi Acosta

Tankiso Mochache

Migraine

History Female, 33 moderate to severe, throbbing head pain most commonly one-sided pain; less frequently both

sides of the head are affected pain located near the eye on affected side pain that worsens with physical activity sensitivity to light and/or sound nausea or vomiting debilitating pain that hinders daily activities untreated attacks most commonly last from four to 72

hours, but may persist for weeks

Migraine

Exam No specific exam findings

Diagnosis The diagnosis of migraine without aura, according to the International Headache

Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria": [43]

5 or more attacks. [For migraine with aura, only two attacks are sufficient for diagnosis]

4 hours to 3 days in duration. 2 or more of the following:

Unilateral (affecting half the head); Pulsating; "Moderate or severe pain intensity"; "Aggravation by or causing avoidance of routine physical activity".

1 or more of the following: "Nausea and/or vomiting"; Sensitivity to both light (photophobia) and sound (phonophobia).

Migraine

Labs None

Imaging None- but a MRI might be ordered to rule out other

conditions

Diff Dx’s Stroke Temporal Arteritis Cluster Headache

Brain Tumor

History Male, 55 Headache Nausea and vomiting Personality or mood changes Seizures Cognitive decline Vision and hearing problems Numbness and tingling into fingers Balance and coordination problems

Brain Tumor

Exam Dilatation of the pupil Hypoesthesia- Pinwheel, Sharp/Dull Memory decline- Can’t remember list of 5 words Ataxia- Romberg’s (eyes open and closed), Tandem Gait,

Finger to nose, Heel to shin Visual field impairment- “H” in space, Visual Acuity,

Visual Fields Impaired sense of smell- CN II Impaired hearing- Weber’s & Rinne-CN VIII Facial paralysis- CN V

Brain Tumor

Labs Lumbar Puncture (Spinal Tap)

No specific tumor markers AFP- alphafetaprotein HCG- human chorionic gonadotropin PLAP- placental alkaline phosphatase

Brain Tumor

Imaging CT- Benign brain tumors often show up as hypodense

(darker than brain tissue) mass lesions MRI- Benign brain tumors appear either hypo- (darker

than brain tissue) or isointense (same intensity as brain tissue) on T1-weighted scans, or hyperintense (brighter than brain tissue) on T2-weighted MRI, although the appearance is variable.

Contrast agent uptake, sometimes in characteristic patterns, can be demonstrated on either CT or MRI-scans in most malignant primary and metastatic brain tumors.

Brain Tumor

Diff Dx’s Menigitis Stroke Neurofibromatosis Type 1 or 2

Tension Headaches

BACKGROUND Tension-type headache represents one of the

most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic or chronic. It had various names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache.

Tension Headaches

Episodic tension-type headache At least 10 previous headaches fulfilling the following

criteria; number of days with such headache fewer than 15 per month

Headaches lasting from 30 minutes to 7 days At least 2 of the following pain characteristics:

Pressing/tightening (nonpulsating) quality Mild or moderate intensity (may inhibit but does not

prohibit activities) Bilateral location No aggravation from climbing stairs or similar routine

physical activity Both of the following:

No nausea or vomiting Photophobia and phonophobia absent or only one present

Secondary headache types not suggested or confirmed

Tension Headaches

Chronic tension-type headache Average headache frequency of more than 15 days per

month for more than 6 months fulfilling the following criteria

At least 2 of the following pain characteristics: Pressing/tightening (nonpulsating) quality Mild or moderate intensity (may inhibit but does not

prohibit activities) Bilateral location No aggravation from climbing stairs or similar routine

physical activity Both of the following:

No vomiting No more than one of the following: nausea, photophobia,

or phonophobia Secondary headache types not suggested or confirmed

Tension Headaaches

Sex Women are slightly more likely to be

affected than men. The female-to-male ratio for TTH is

approximately 1.4:1. In CTTH, female preponderance is 1.9:1.

Age TTH can occur at any age, but onset during

adolescence or young adulthood is common. It can begin in childhood

Tension Headaches

History Tension-type headaches (TTHs) are characterized by pain

that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common).

Ulrich et al reported that 82% of TTHs last less than 24 hours.2

The deep steady ache differs from the typical throbbing quality of migraine headache. Prodrome and aura are absent. Occasionally, the headache may be throbbing or unilateral, but

most patients do not report photophobia, sonophobia, or nausea, which commonly are associated with migraine.

Some patients may have neck, jaw, or temporomandibular joint discomfort.

Tension Headaches

Physical Exam Patients with TTH have normal findings on

general and neurologic examinations. Some patients may have tender spots or

taut bands in the pericranial or cervical muscles (trigger points).

Tension Headache

Causes Various precipitating factors may cause TTH in

susceptible individuals. One half of patients with TTH identify stress or hunger as a precipitating factor.

Stress - Usually occurs in the afternoon after long stressful work hours

Sleep deprivation Uncomfortable stressful position and/or bad posture Irregular meal time (hunger) Eyestrain Other common reasons lead to a tension headache

include performing an activity that causes you to hold your head in one position for a long time (like using a computer, microscope, or typewriter), sleeping in a cold room or an abnormal position, overexerting yourself, clenching your jaw or grinding your teeth.

Tension Headaches

Imaging Studies Neuroimaging studies are important to rule out

secondary causes of headache, including neoplasms and cerebral hemorrhage.

MRI imaging shows the greatest detail of cerebral structures and is especially useful in evaluating the posterior fossa.

CT scan with contrast is a viable alternative but is inferior to MRI for viewing structures in the posterior fossa.

Neuroimaging is indicated if the headaches are atypical in any way or if they are associated with abnormalities in the neurologic examination.

Aseptic Meningitis

Aseptic meningitis is an illness characterized by serous inflammation of the linings of the brain (ie, meninges), usually with an accompanying mononuclear pleocytosis. Clinical symptomatology is varied and includes predominantly headache and fever. The illness is usually mild and runs its course without treatment; however, some cases can be severe and life threatening.

Aseptic Meningitis

Frequency Aseptic meningitis is one of the most

common infections of the meninges. It occurs in individuals of all ages, although it is more common in children, especially during summer. No racial differences are reported. Aseptic meningitis tends to occur 3 times more frequently in males than in females. In meningitis caused by the mumps virus, both sexes are affected equally

Aseptic Meningitis

Causes Overall, viral infection is the most common form of

aseptic meningitis and enteroviruses are the most common causes of viral aseptic meningitis. Recent findings show that enteroviruses remain the most common cause of aseptic meningitis. Certain enteroviruses (eg, coxsackie B5, echovirus 6, 9, and 30) are more likely to cause meningitis outbreaks, while others (coxsackie A9, B3, and B4) are mostly endemic.1 Other viral agents include the enteroviruses, herpesviruses, and HIV. HIV may cause aseptic meningitis, mostly at the time of seroconversion. While HIV spreads via the hematogenous route, rabies, polio, and herpesviruses are neurotrophic (ie, spread through neurons).

Aseptic Meningitis

Pathophysiology When the protecting barriers of the brain, including

the skull, meninges, and blood-brain barrier, are broached by a pathogen, meningitis can result. Predisposing factors include preexisting diabetes mellitus, immunosuppression, otitis media, pneumonia, sinusitis, and alcohol abuse. Meningeal inflammation and irritation elicit a protective reflex to prevent stretching of the inflamed and hypersensitive nerve roots, which is detectable clinically as neck stiffness or meningeal signs. Meningeal irritation due to inflammation also may cause headache and cranial nerve palsies. When cerebral edema and elevated intracranial pressure occur, alterations in mental status, headache, vomiting, seizures, and cranial nerve palsies may ensue.

Aseptic Meningitis

Signs Neck stiffness in meningitis is tested by

gentle forward flexion of the neck with the patient lying in the supine position. Meningeal irritation also can be tested by the jolt accentuation of headache. This is tested by asking the patient to turn his or her head horizontally at a frequency of 2-3 rotations per second. Worsening of a baseline headache represents a positive sign

Aseptic Meningitis

Signs Cont… When passive neck flexion in a supine patient

results in flexion of the knees and hips, a positive Brudzinski sign is entertained. Yet another sign, the contralateral reflex, is present if passive flexion of one hip and knee causes flexion of the contralateral leg.

Kernig sign is elicited with the patient lying supine and the hip flexed at 90°. A positive sign is present when extension of the knee from this position elicits resistance or pain in the lower back or posterior thigh

Aseptic Menigitis

Lab Tests CBC, differential, platelet count Sedimentation rate, antinuclear antibody,

rheumatoid factor Sjögren syndrome antigens A and B Serum protein electrophoresis Lyme titer (enzyme-linked immunosorbent assay

[ELISA]) VDRL, fluorescent treponemal antibody absorption

test (FTA-ABS) Acute and convalescent sera for virus-specific IgG

or IgM to enteroviruses, arboviruses, adenoviruses, LCMV, Epstein-Barr virus, and HSV-2

Aseptic Meningitis

Imaging Studies Chest x-ray, posteroanterior and lateral MRI of brain/spine

Headache/Head Pain

History and Examination

Determine whether the patient has a secondary cause for the headache, such as trauma, metabolic disease, toxic (drug) effect, infection, or intracranial pathology.

Determine whether the patient’s headache fits one of three categories of primary headache: migraine, tension-type, and cluster or whether cervicogenic is likely.

Determine whether there are any obvious triggers or patterns to the headache from environmental, dietary, or medication sources.

Evaluate the patient for musculoskeletal factors that may cause or influence headaches.

Determine any red flags suggestive of referral for medical management.

History cont.

Attempt to distinguish the type of headache by using the headache diary or questionnaire for headaches.

For example:1. Did you hit your head? Did you lose

consciousness and have difficulty with memory?

2. Do you have any medications? Did you recently stop taking medication?

3. Is this a “new” headache? Is the headache throbbing at your temple? Is there associated vision loss with this temple headache?

Examination

The primary role of the standard physical examination is to rule out secondary causes of headache such as tumor, infection, intracranial hemorrahage, and glaucoma.

A thorough neurologic examination must be performed, emphasis on cranial nerve, vestibular, and pathologic reflex testing is necessary to rule out referrable disorders.

With manual palpation you’re looking for: Intersegmental hypomobility ( primarily in the upper

cervical area) Specific tender points Dysfunctional motion of the cervical spine Postural imbalance (forward head position and round-

shoulder appearance.)

Imaging

Radiologic or advanced imaging for headache is still controversial.

The literature suggests that the use of special imaging is rarely justified with headache sufferers.

DDX

In the chiropractic office the most common headache presentation is associated with whiplash.

Chronic headache that is unresponsive to treatment is difficult to pinpoint and one of the most likely culprits is a TMJ disorder.

Statistics: Migraine is prevalent in 6.5% of males and

18.2% of females. Prevalence increases from age 12 to 40 and

then declines. 27.9 million Americans suffer from migraine

TMJ Headaches

History

A 16 year old female in northern Texas was experiencing extreme jaw pain on both sides of her face near the ears. She had orthodontics for straightening her teeth six months ago. She had been experiencing painful clicking and popping in both ears for 18 months. She had not had any accidents or trauma to her head or neck. The pain had been getting worse the last few months, and she could not open her mouth wide without pain and was having problems chewing.

History cont.

Key questions that are important to ask during the history evaluation:

Was there a direct blow to the jaw? If so, you are thinking fracture, disc derangement

Does your jaw lock? Closed lock, acute open lock

Is the complaint more one of popping or clicking? Hypermobility of the TMJ

Is the pain worse with chewing? Dental pathology, TMJ synovitis

Do you have cervical spine pain or headaches? Possible referral to TMJ, check forward head posture

Examination

Examination of the TMJ focuses on two main bodies of information:

1. mandibular “gait” analysis palpation with auscultation 2. palpation combined with provocative maneuvers

including compressive, stretch, and contractile challenge. A secondary evaluation focuses on possible involvement of

dental and cervical spine contributions. The degree of opening can be measured with a ruler in

millimeters. Another approach is to use the patient’s own knuckles as a patient specific approach. The general rule of thumb is that if the patient can open two or two and a half knuckles is considered normal. Less than two knuckles suggests hypomobility, more than three suggests hypermobility.

Examination cont.

General testing of jaw opening and closing may give clues to muscle involvement due to an increased pain response.

Postural evaluation is an important component TMJ evaluation. The most common postural abnormality is a forward head position with a compensatory extension of the head to correct for visual requirements.

Although the initial flexion component of the forward head position causes the mandible to translate down and forward, the compensatory extension forces the mandible posteriorly, potentially irritating the retrodiscal tissue.

Imaging findings

Radiographic evaluation of TMJ disorders may be valuable when TMJ tomograms are employed. Standard radiography of the joint rarely provides any additional information.

DDX

Chronic headache unresponsive to treatment is a difficult scenario. First on the list of possibilities should be temporomandibular joint disorders. It overlaps with clinical indicators of tension- like headaches.